Archive for March, 2010

Autism has become one of the biggest issues facing our schools and our insurance companies today. Many people do not understand that there can be differing degrees of autism. Some children diagnosed with autism are considered to be high functioning and will join society as they age if they are given proper diagnosis and therapy throughout. Others with the diagnosis of autism will not function on their own regardless of assistance from schools and doctors. While I was a school nurse, I cared for a family of six children where five of them had differing degrees of autism diagnosis. Two of the children were incapable of performing any care for themselves at the ages of ten and twelve as they were developmentally approximately 18 months. This was a terrible hardship on the family. The children were sent to school as respite for the parents but were incapable of learning and took time away from the other special needs children in their classrooms. Three of the children functioned at the developmental age of four year olds and had some ability to perform their ADL’s and to participate in the classroom. The last child had no autism diagnosis and functioned at the appropriate developmental age. I cannot imagine the difficulties that this family faces on a daily basis.

Original PostMarch 10, 2010Title: Autism TodayInformation regarding the disorder of Autism is certainly prevalent in our world today. The “Autism Speaks” organization advertises on television that one in one hundred fifty children are afflicted with the disorder. If correct, these are alarming statistics. It is well documented that all socioeconomic groups and boys more than girls are impacted. The diagnostic process often begins when toddlers do not meet speech and other developmental milestones. The current impact to our schools and other systems as attempts to assimilate the children into society are overwhelming at best. The long-term impact to society and public health resources related to the special needs of this group are yet to be fully realized. The impact on a family is more than those of us not experiencing it can understand. I know well a family in which two out of three children are diagnosed as Autistic. One child is profoundly challenged while the other is able to attend schools, but is clearly socially challenged. The family dynamics were not uncommon. The father enmeshed himself in work. The mother blamed herself for being unable to manage her children. It was a very unhappy home. Health care visits did not readily detect the issues for some time, which allowed denial, frustration and blame to continue. It was interesting to observe the relief when finally having a diagnosis and access to the treatment that would ultimately begin to improve the situation. The state of Arizona recently passed legislation requiring insurance companies to fund advanced therapy for Autistic children. Proponents of the bill contended that the early intervention costs would be offset by costs later in life once the children are able to contribute to society. Those arguing against the bill stated that costs will be passed on to all and that it is unlikely that profoundly Autistic children will ever be emancipated from the health care system. Also of note is the fact that our textbook, Health Promotion Throughout the Lifespan, 6th Edition, by Edelman and Mandle does not directly address Autism, probably because it was last updated in 2006. Certainly upcoming editions will address the disorder along with the role of the nurse in working with the child and family members. This is a good example of how the Internet and other sources can provide real time information.

Health Assessment is now frequently being done by electronic medical records. The large medical practices in my town have spent many thousands of dollars to upgrade the old dictation methods in their office to electronic entry. This will be wonderful for the patient records end, however it comes with a problem. Many of my patients say the doctor used to sit and talk with them and give them eye contact. Now they are so busy doing data entry that they don’t even look at the patient. Their eyes are focused on the computer. This gives the patient a feeling of not being cared about. Computer medical data entry of our assessments have de-humanized the client / provider relationship. This is sad.

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Information regarding the disorder of Autism is certainly prevalent in our world today. The “Autism Speaks” organization advertises on television that one in one hundred fifty children are afflicted with the disorder. If correct, these are alarming statistics. It is well documented that all socioeconomic groups and boys more than girls are impacted. The diagnostic process often begins when toddlers do not meet speech and other developmental milestones. The current impact to our schools and other systems as attempts to assimilate the children into society are overwhelming at best. The long-term impact to society and public health resources related to the special needs of this group are yet to be fully realized. The impact on a family is more than those of us not experiencing it can understand. I know well a family in which two out of three children are diagnosed as Autistic. One child is profoundly challenged while the other is able to attend schools, but is clearly socially challenged. The family dynamics were not uncommon. The father enmeshed himself in work. The mother blamed herself for being unable to manage her children. It was a very unhappy home. Health care visits did not readily detect the issues for some time, which allowed denial, frustration and blame to continue. It was interesting to observe the relief when finally having a diagnosis and access to the treatment that would ultimately begin to improve the situation. The state of Arizona recently passed legislation requiring insurance companies to fund advanced therapy for Autistic children. Proponents of the bill contended that the early intervention costs would be offset by costs later in life once the children are able to contribute to society. Those arguing against the bill stated that costs will be passed on to all and that it is unlikely that profoundly Autistic children will ever be emancipated from the health care system. Also of note is the fact that our textbook, Health Promotion Throughout the Lifespan, 6th Edition, by Edelman and Mandle does not directly address Autism, probably because it was last updated in 2006. Certainly upcoming editions will address the disorder along with the role of the nurse in working with the child and family members. This is a good example of how the Internet and other sources can provide real time information.

I couldn’t agree more with the writer of this discussion forum. I have learned much more from this course than if I was sitting in a traditional classroom. I am able to proceed at my own speed. I can concentrate more on the systems of the body where my knowledge is lacking and less on the systems I know better. It is less stressful also to be able to take quizzes and tests when I actually have time as opposed to on a schedule set by someone else. I can do my readings when I am at my best instead staying up half the night trying to complete them in time for the next class. It has forced me to really utilize my time management skills.

Original PostMarch 4, 2010Title: Advanced Physiological Nursing Course Via Internet LearningThis was a great course, I feel as though I learned more than I would have sitting in a classroom because I not only had to do the reading but also had to research the Internet to find answers and explanations to questions I didn’t know, was unsure about, or didn’t understand. In many ways this course was harder than the past physiology course I took sitting in a classroom. I think in the classroom it is all too easy for instructors to teach to their test (either subtly or overtly) because their success is on the line. With an Internet course the ability to pass the class and do well rests with me. My goal was to come into this class and learn as much as I can, give more than 100% and achieve the highest possible grade I can earn. I feel as though I have accomplished the first goals and will await taking the final to see if I have achieved my last goal of an A in this course.

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I have been touched by the many recent news headlines of medication errors, especially those involving newborns. In yesterday’s news covering a Las Vegas malpractice case, a sobbing pharmacist was apologizing to the parents of a deceased infant who was the recipient of a drug overdose prepared during her watch. The pharmacist was so distraught that the mother of the deceased infant left her seat in the court room to comfort her. Our text discusses the potentially harmful effects of medications during pregnancy, during labor, and to newborns. In watching the coverage and reading the text, I was reminded of the many times during my career that I have witnessed errors and myself experienced serious near misses with medication administration. It is devastating when such events occur to both the patient and the health care practitioner. Safe administration of medications has always been the goal of healthcare providers, but it seems that despite all of the resources available, errors continue at alarming rates. This is so much the case that The Joint Commission has charged hospitals to improve the safety of medication administration in their National Patient Safety Goals. Information regarding dosing, drug interactions, etc. is readily available in many formats to those preparing and administering medications. We have medications provided in unit dose increments and dispensed by machines. As a standard of nursing care, we perform a minimum of five checks before administering medications. Some medications require two nurses to verify the dose. We have changed our practices with patient identification to reduce the likelihood that medication is given to the wrong person. Yet, with all of the available information and redundancies built into the system, life threatening errors occur. There is a federal movement underfoot for all healthcare organizations to have electronic medical records in place. A medication administration record that does not require manual transcription would be an adjunct in reducing transcription errors. However, the data base is only as good as the information that it is provided with, leaving the potential entry for errors. Electronic data bases provide very useful information for tracking, measuring and determining clinical quality. This would help us evaluate process errors and to revises processes based on the knowledge gained. At the end of the day, with all the tools and information at hand, it is the end user who is the last and most important stopgap in safe medication administration. The available tools are like a hammer. A great hammer still needs a skilled carpenter to achieve a great outcome. It is my belief that our focus should be in development of the “carpenter” and the processes used by the “carpenter” with regard to medications. This would involve more training with medications; time to recalculate what is prepared in pharmacies, and an evaluation of the environment, including patient assignments and ratios. The costs incurred would be minimal compared to the cost of a human life or a lawsuit related to negligent practice.

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This was a great course, I feel as though I learned more than I would have sitting in a classroom because I not only had to do the reading but also had to research the Internet to find answers and explanations to questions I didn’t know, was unsure about, or didn’t understand. In many ways this course was harder than the past physiology course I took sitting in a classroom. I think in the classroom it is all too easy for instructors to teach to their test (either subtly or overtly) because their success is on the line. With an Internet course the ability to pass the class and do well rests with me. My goal was to come into this class and learn as much as I can, give more than 100% and achieve the highest possible grade I can earn. I feel as though I have accomplished the first goals and will await taking the final to see if I have achieved my last goal of an A in this course.

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In August our hospital implemented the e-mar – electronic medication administration record – documentation system. It was decided by the powers to be that a "Big Bang" roll-out would work much more efficiently than trialing the system on one unit first. This decision was made despite the months of "team" meetings where numerous members of lower Leadership expressed their concern and apprehension. Part of the package purchased with the software contract included on-site program developers and support. It was with this promise of guidance and support, that we were urged forward – pressured into meeting our initial launch date. It was said that we were facing a change in "thought process" among the older staff members – we were told that once the product was on the units that "buy in" would be quick – that the system was here to stay and the staff would have no choice but to adapt and accept. It has been and absolute nightmare to say the least. We have literally two nurses assigned to our computerized programming department. Neither one has had actual computer training other than what the emar company has provided. The provided program developers are nonclinical based professionals trying to create in a clinical field. Input from participating departments is often dismissed. Instruction to the staff has been inconsistent with unit based nurse clinicians being forced to teach computer classes with minimal orientation and little to zero resources. Feedback to staff over system errors, challenges and restrictions is inconsistent and varies depending on who is delivering the message. The list could go on for pages and has created dismay and distrust, a sense of failure within the Nursing department. Pharmacy has had an even more difficult struggle – expressing their concern over the timing and method of implementation during a period that their department had several vacant positions, including that of a department director – but we had a deadline to meet after all. In addition we have since discovered that there are several different software systems being utilized throughout the organization, L&D, ASU, Endo, OR, IRU, Dialysis, offsite, Dental and ER – to name a few. Not only do these systems not communicate with each other but they are for the most part not able to effectively incorporate the e-mar system. This has created an environment of half paper half electronic documentation, inconsistent between departments. Errors are being made, system failures and limitations are not being addressed within a timely fashion – if at all. With that said, the e-mar system may be more time efficient, cost effective, and allow for increased patient safety…but without expertly trained program developers, consistent clinical based instructors, adequate and around the clock implementation support staff, consistent and accurate communication between all departments of the organization – including frontline staff, realistic goals and time lines and the ability to make corrective and adaptive changes – the transition for the staff can become difficult, frustrating and unsafe for both patients and healthcare professionals alike.

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I absolutely agree with all the comments presented in the below link. Being that computerized documentation is less than 6 months old in our main facility, bedside point of care charting is a relatively new concept. It used to be that the only documentation performed at the bedside was the patient database and even then, most of that information was gathered on initial assessment and we would then go out to the desk to complete the paperwork. I think as more organizations embrace technology, more thought needs to go into the purchasing of equipment. At our facility, the managers for each unit were given a budget to purchase the style of computer they thought would be best suited for that particular unit. Pods were designed with central computers, handheld devices were purchased as well as COWs (computer on wheels). Many units after the fact discovered that the COWS were too big to get to the second bed in the room. This caused non-compliance with The Joint Commission standard stating that the e-mar must be at the bedside when administering medications. Other units found the hand held devices to small to use – the type to difficult to read. Pods are great for the primary nursing concept but takes the nurse away from the bedside. Many areas discovered just how few available outlets they had how short a battery life really is. We even had to become politically correct when a patient complained to administration that she overheard a nurse in the ER referring to "that stupid COW that had died in the hallway" – not realizing the nurse was frustrated that no one had bothered to plug the computer in to charge. We now refer to COWS as WOWS – work stations on wheels. With all that aside, we are finding that wall based point of care computers work best allowing optimal contact with the patient while gathering crucial information to be utilized in their treatment of care – as long as the computer is not on a wall that forces your back to the patient the entire time you are typing!

Original PostDecember 14, 2009Title: Assessments and Point of Care ChartingCharting patient assessments is often a time consuming task, but vital to the care of the patient and record keeping. Nursing often jot notes down on a piece of paper, to only later record them into the computer system. Much may be lost in the translation. In addition, actions may be taken on the charting that in currently in the computer, though it may not always be the most current reflection of the patent’s status. Point of care systems have become paramount for charting in acute care settings, especially on critical care units. They often interface with medical devices to collect data automatically. These systems are often flowsheet orientated and provide graphing and trending capabilities. Optimally these systems create less redundancy, offer quick responses and interface with other clinical operations such as the laboratory and pharmacy departments. The computer availability is also an important consideration. Central computers have not always enhanced charting as they may take nurse from the bedside. Point of care charting should be convenient points of access to the system. Computers on Wheels (COWS) are found in many organizations. The portable, efficient system allows the nurse to chart in the patients room when appropriate. Bedside systems at the point of care focus on quickly capturing information that a nurse may otherwise jot down on their notes. Computer location should be given thoughtful consideration before investments are made in addition to the device’s speed and ease of use.

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Part of my role as a nurse clinician is that of ensuring that a newly hired RN is able to independently pass medications. Our facility policy is to have the initial med pass performed with a clinician and once deemed competent the new hire can continue medication administration under the supervision of a nurse preceptor (another RN assigned to that nurse). Like most hospitals, the demand to push these new nurses through the orientation process and into independent practice is tremendous. We often short come the orientation and nurses today are learning on the fly. A proper preceptorship should consist of a seasoned and experienced RN with a smaller patient load, working with the new hire and delegating tasks until they feel the new nurse can perform and handle a patient load on their own. In the real world – the new hires are often treated as additional staff and the preceptor is ending up with double the patient assignment because they have an "extra" pair of hands. The preceptor is so busy trying to complete and care for the additional patients the new hire is often left unattended. During an observed medication pass this morning I was dismayed to watch the nurse flip to the drug information screen on her e-mar instead of actually taking the time to look up the medication in a drug guide. Was it more time effective? Yes, but she just glanced at the first sentence or two grabbed a keyword and assumed that was the drug’s intention. A few times I had to encourage her to go back and read the entire screen – point out that she was glossing over key information such as adverse reactions or drug interactions. With all the tremendous technological advancements we are making in healthcare today, I hope it is not as the cost of patient safety and nursing accountability.

Original PostJanuary 4, 2010Title: Charting in the Era of EMRI am still of the era of nurses that entered a patients room with my rounds sheet tucked into my uniform pocket. The secret was to not let the patient see this sheet, and be able to remember their name, main diagnosis, and what you needed to check in them. You would go through your complete assessment including vital signs, and when you left the room you would pull out your little sheet of paper and write down all of the information you just collected. This procedure was repeated for all eight of your patients. When you were done, you then sat at the nurses’ station and pulled the individual charts so you could transfer the information onto the required forms.

It is not hard to see how the electronic medical record has benefited the role of nursing. The first improvement is in time management. You can actually take the information and enter it once. This is the only time you write the information. The second advantage is in correct data entry. You can enter the data as you gather it. There is less chance of forgetting the information before you write it in the patient record. The third benefit is in gathering the correct information on each patient. Electronic medical records prompt you to gather the required information.

I speak purely from a hypothetical standpoint because I personally have not had the chance to utilize an electronic medical records system. Our hospital is still struggling to come up with the money required to purchase and implement a system. I can, however, dream about how easy it will make my life once we get one!!!

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I think the biggest hurdle I’ve encountered with the decision to obtain an online degree, is the time management. I have never been a master of my time to begin with and trying to juggle the children, a full time job and school – amongst the hundreds of other commitments we all have, has been quite a struggle for me. I envisioned putting the children to bed with plenty of free time at night to study on line. I now realize that 1000 at night is not necessarily the optimal time to read and retain learning material. I also wished I had taken in account how stressful it can become when your taking a timed exam and the kids are running in and out of the room while the incoming calls are knocking offline! (yes I live in one of the few areas in New York that still uses dial-up service) If any, an important lesson I have learned throughout this experience is to impart time management unto my children – that it is an essential skill needed not just in healthcare but in life in general.

Original PostFebruary 1, 2010Title: Choices that prepared me for my online nursing classesWe all made choices about the types of courses we wanted to take when we were in junior high school and high school. I went to high school long before the age of computers but know one course choice I made in 8th grade prepared me well for this class. No, it wasn’t a science class or a health class but instead it was a typing class. I cannot imagine doing the homework assignments if I couldn’t type fast. Thank you to my parents for encouraging me to take typing, I remember telling them, it was a waste of time and I wouldn’t need it as a nurse. I apologize to them both and thank them for guiding me well.